A client has sustained a crush injury to the abdomen as the result of an industrial accident. The initial assessment and interventions have been carried out. The vital signs are stable and the family is at the bedside. The client is complaining of bilateral flank pain. What is the priority nursing action for this client now?
Prepare for immediate abdominal surgery
Determine if there are any allergies to food or drugs
Administer antibiotics as ordered after culture results are available
Obtain a urine specimen
The Correct Answer is D
A. Prepare for immediate abdominal surgery
There is no indication of active hemorrhage or peritonitis at this point. Further assessment is needed before deciding on surgery.
B. Determine if there are any allergies to food or drugs
Allergy history is important, but it is not the immediate priority for this client.
C. Administer antibiotics as ordered after culture results are available
Antibiotics may be needed if infection is suspected, but the priority is assessing kidney function due to the risk of rhabdomyolysis from muscle breakdown.
D. Obtain a urine specimen
Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. The urine should be tested for myoglobinuria (tea-colored urine), hematuria, or kidney injury markers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. A
Patients with A- blood type have A antigens on their red blood cells and do not have the Rh factor (negative). They can receive A- blood because it has the same antigens and Rh factor, making it a perfect match.
B. O+
Rh-negative clients cannot receive Rh-positive blood, as it may trigger an immune reaction.
C. AB-
Type AB blood contains A and B antigens, which A- individuals do not naturally have, increasing the risk of a transfusion reaction.
D. A+
A Rh-negative (A-) client cannot receive Rh-positive (A+) blood due to the risk of Rh sensitization.
E. O-
O- blood is the universal donor for red blood cells, meaning it contains no A, B, or Rh antigens, making it safe for an A- recipient.
Correct Answer is C
Explanation
A. Urine output of less than 0.5 mL/kg
Norepinephrine is a vasopressor used to improve perfusion. A urine output of less than 0.5 mL/kg suggests ongoing hypoperfusion and inadequate organ perfusion, which is an undesirable outcome.
B. Improved mental status, decreased lactate level
These are positive indicators of improved perfusion and oxygen delivery, but they are not the primary target for norepinephrine therapy.
C. A mean arterial pressure (MAP) of 65
A MAP of at least 65 mmHg is the target for vasopressor therapy, as it ensures adequate perfusion of vital organs.
D. A pain level of 4 or less on a scale of 0-10
While pain management is important, norepinephrine’s primary role is not pain control but rather maintaining adequate perfusion.
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